Provider Demographics
NPI:1487047197
Name:SEASIDE DENTAL CLINIC
Entity type:Organization
Organization Name:SEASIDE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:O
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-738-6520
Mailing Address - Street 1:729 S HOLLADAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138
Mailing Address - Country:US
Mailing Address - Phone:503-738-6520
Mailing Address - Fax:503-738-6556
Practice Address - Street 1:729 S HOLLADAY DRIVE
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138
Practice Address - Country:US
Practice Address - Phone:503-738-6520
Practice Address - Fax:503-738-6556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD83331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty